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American Journal of Psychiatric Rehabilitation Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uapr20
Subjective Experiences of Clients in a Voluntary Money Management Program Kristin L. Serowik M.A. a
a c
a
, Chyrell D. Bellamy ,
Michael Rowe & Marc I. Rosen
b c
a
Department of Psychiatry , Yale University School of Medicine , New Haven , Connecticut , USA b
Department of Psychiatry , Yale University School of Medicine, New Haven, Connecticut , West Haven , Connecticut , USA c
VA Connecticut Healthcare System , West Haven , Connecticut , USA Published online: 29 May 2013.
To cite this article: Kristin L. Serowik M.A. , Chyrell D. Bellamy , Michael Rowe & Marc I. Rosen (2013) Subjective Experiences of Clients in a Voluntary Money Management Program, American Journal of Psychiatric Rehabilitation, 16:2, 136-153, DOI: 10.1080/15487768.2013.789699 To link to this article: http://dx.doi.org/10.1080/15487768.2013.789699
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American Journal of Psychiatric Rehabilitation, 16: 136–153, 2013 Copyright # Taylor & Francis Group, LLC ISSN: 1548-7768 print=1548-7776 online DOI: 10.1080/15487768.2013.789699
Subjective Experiences of Clients in a Voluntary Money Management Program Kristin L. Serowik Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA; VA Connecticut Healthcare System, West Haven, Connecticut, USA Chyrell D. Bellamy and Michael Rowe Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA Marc I. Rosen Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut, USA A large proportion of people diagnosed with mental illnesses have difficulty managing their money, and therefore many psychiatric treatments involve providing money management assistance. However, little is known about the subjective experience of having a money manager, and extant literature is restricted to people forced to work with a representative payee or conservator. In this study, fifteen people were interviewed about their experience receiving a voluntary money management intervention designed to
This work was supported in part by grants DA12952, DA025613, and MH083394 to Dr. Rosen. The authors would like to thank Lisa Fenton, PsyD, and Anne Black, PhD, for conducting the qualitative interviews. Address correspondence to Kristin L. Serowik, M.A., Department of Psychiatry, Yale University School of Medicine, 34 Park St., New Haven, CT 06519, USA. E-mail: [email protected]
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minimize substance use. Clients emphasized the importance of trusting the money manager, financial mindfulness (an enhanced awareness of the financial transactions in clients’ day-to-day lives), agency over their own affairs, and addiction. In contrast to evaluations of people assigned representative payees or conservators, there was little mention of feeling coerced. These findings suggest that money management programs can address client concerns by building trust, relating budgeting to clients’ day-to-day lives, and encouraging clients’ control over their own affairs. Keywords: Money management; Poverty; Serious mental illness; Social Security; Substance use
The lives of many people with severe and persistent mental illnesses are made harder by poverty. (Frank & Glied, 2006). Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) provide funds for disabled people to meet their basic needs, albeit at the cost of their adopting a self-identification as ‘‘disabled’’ (Estroff, Patrick, Zimmer, & Lachicotte, 1997). SSI and SSDI also facilitate access to other resources such as case management, health insurance, housing assistance, and vocational support (Frank & Glied, 2006). A substantial proportion of people disabled by severe and persistent mental illness have unmet money management needs. A high proportion have been found to be financially victimized (Conrad et al., 2006), unable to meet basic needs (Rosen et al., 2002a), extensively indebted (Jenkins et al., 2008), and frequently homeless or in psychiatric hospitals because of mismanaged funds (Hanrahan et al., 2002). Problems managing funds are especially pronounced among people with mental illness who also abuse substances (Rosen et al., 2002b). Substance abuse reflects money mismanagement when drugs and alcohol are purchased with SSI and SSDI benefits; sometimes drugs are purchased at the same time of the month the disability checks are received (Rosen, 2011). Clients who relapse to substance use are at heightened risk of losing their housing (Goldfinger et al., 1999; Lipton, Siegel, Hannigan, Samuels, & Baker, 2000). In part because substance abuse can lead to homelessness, substance use was the most common reason cited for assigning a representative payee among surveyed case managers (Luchins et al., 1998). To address client difficulties with their finances, many psychiatric treatments and psychosocial rehabilitation programs involve
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138 K. L. Serowik et al. providing money management assistance. Examples include supportive housing (Kertesz & Weiner, 2009; Tsemberis & Eisenberg, 2000), supportive employment (Bond, Drake, Becker, & Mueser, 1999), and assertive community treatment programs (Neale & Rosenheck, 2000). One particular widely employed money management intervention is the administrative assignment of a representative payee to store, manage, and dispense beneficiary funds. Approximately 30% of beneficiaries receiving SSI or SSDI, for example, are mandated to have a representative payee (Social Security Administration, 2006; 2007). Fortunately, assignment of representative payees when those payees are affiliated with treatment facilities has been associated with a variety of benefits including higher attendance at outpatient treatment (Ries & Comtois, 1997), better client-reported quality of life, a decrease in alcohol and illicit drug use, and better management of funds (Conrad et al., 2006; Rosen, 2011). Money management is increasingly considered to be a therapeutic intervention (Rosen, Bailey, & Rosenheck, 2003). Descriptions of clients’ subjective experience of money management interventions have been limited to clients who have been assigned representative payees, usually those affiliated with clinical programs. Dixon and colleagues (Dixon, Turner, Krauss, Scott, & McNary, 1999) interviewed 54 clients and their case managers in a payee program based at a community mental health center concerning client attitudes toward the payee program. Overall satisfaction with the program was high, but the most satisfied clients were those who had been in the program for over a year. These high satisfaction ratings may have been associated with selective retention of satisfied clients. Tension in the client-payee relationship was reflected in the fact that case managers for 44% of clients reported that their client had been verbally abusive in connection with representative payee activities (Dixon et al., 1999). In a series of case reports, Brotman and Muller (1990) described the potential for boundary confusion when the client’s payee was also the client’s clinician. Some clients became agitated because of feeling engulfed, controlled, or overly dependent on the payee-therapist. Another explanation that has been offered for tension between client and payee-clinicians is that clients may feel that their clinician misused the financial control of being a payee to force the client to comply with treatment (Angell, Martinez, Mahoney, & Corrigan, 2007; Hanrahan et al., 2002). A substantial minority of clients for whom
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Subjective Experience of Money Management 139 money manager and clinician functions are performed by different people (Shaner, Tucker, Roberts, & Eckman, 1999; Ries & Dyck, 1997) also report feeling coerced by their representative payees, although most clients report high overall satisfaction with the payee arrangement (Rosen, Desai, Bailey, Davidson, & Rosenheck, 2001). Clients’ experience of having a representative payee is influenced by the fact that payee assignment is typically recommended by a third party, mandated by an outside agency (the Social Security Administration), and involves loss of legal and fiduciary autonomy. It is not known whether the issues described by assigned representative payees are inherent to and characteristic of all money management interventions, voluntary or not. The study we report in this article was undertaken to address this gap in the literature by asking clients their experience of voluntary money management intervention. We hypothesized that a voluntary money management program would be experienced empowering rather than patronizing because it offered clients the opportunity to use money to further personal goals. Clients who had been assigned to a voluntary money management intervention in a randomized clinical trial were sought after the study ended for qualitative interviews concerning their experience of the money management intervention. METHOD
Participants In the parent clinical trial, participants with a history of cocaine or alcohol abuse who were in psychiatric treatment at an urban community mental health center were invited to participate in a 9-month clinical trial comparing a money management intervention focused on substance abuse counseling called advisor-teller money manager (ATM) (Rosen et al., 2003), with a control condition receiving financial education (details about study in Rosen, Rounsaville, Ablondi, Black, & Rosenheck, 2010). ATM participants were encouraged to have their checks sent directly to the money manager and deposited into a pooled account. The money manager paid clients’ bills directly and gave the client disbursements for budgeted expenses. Participants in ATM met with the money manager weekly for financial and substance use counseling. As part of the financial counseling, the money manager planned monthly budgets with clients and
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140 K. L. Serowik et al. taught each client how to track expenses. Participants were asked to link their spending to an abstinence-related activity during the upcoming week. A breathalyzer and on-site urine toxicology screen were analyzed at the weekly sessions, and substance use episodes were reviewed to plan alternative activities and expenditures. In the parent clinical trial, participation in ATM was extensive, with clients attending an average of 22.5 sessions during the 36-week intervention and many opting to store their funds with the money manager. Of those assigned to ATM, 33% had funds deposited to the pooled account, 35% had their checkbook stored by the money manager, and 13% had both their funds and checkbook stored by the money manager. Compared with the control group, ATM participants used less cocaine over time. There was no difference in the proportion of patients attending nonstudy treatment by group, indicating that ATM neither facilitated treatment at the mental health center nor substituted for it. There was a serious adverse event in which a study participant in ATM assaulted the money manager when she did not have his money, and another participant became agitated when he was assigned a conservator. Approximately 1 year after completion of the clinical trial, persons who had been randomly assigned to the ATM counseling were recruited by flyers posted at the mental health center and by asking their clinicians to inform them of this qualitative study. Because recruitment was at the mental health center, only participants who were in treatment at the mental health center 1 year after the parent study learned about the study. Sixteen of the 47 individuals in the ATM counseling of the parent clinical trial were approached to undergo interviews, and 15 were enrolled. Neither the assaultive nor the agitated participants from the parent trial enrolled in this interview study. All 15 study participants were receiving SSI and=or SSDI. Their mean age was 44 (SD ¼ 9.4) and mean GAF score was 42 (SD ¼ 5). Altogether, 56% of participants were Black, 28% were White, and 16% Hispanic. Fifty percent had a diagnosis of bipolar disorder; 28.6% had schizophrenia or a similar disorder; 21.4%, major depression; and 6.7%, psychosis not otherwise specified. Forty percent reported cocaine use in the previous 28 days and 53.3% reported using alcohol in the prior 28 days. The 15 ATM participants who took part in the qualitative interviews were compared with the 32 ATM participants who did not.
Subjective Experience of Money Management 141 The only significant difference between the groups was that the qualitative study participants had attended more therapy sessions (M ¼ 30.6, SD ¼ 18.07) than did the ATM participants who were not in the qualitative study (M ¼ 18.69, SD ¼ 12.7), t(45) ¼ 2.61, p < .01.
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Procedures Each participant completed two separate in-depth interviews a week apart with different interviewers. The interviewers included a psychiatrist (M.I.R.) and two psychologists who had experience working with disenfranchised populations. After informed consent was obtained, participants were interviewed in an office at the mental health center. All interviews were audiotaped, and the first interviews were transcribed and analyzed. Second interviews were conducted to supplement the initial interviews, using the same prompts but a different interviewer.
Materials The interviewer was given a list of prompt questions to elicit the clients’ views about their participation in the ATM program. (Interview prompts are available on request.) The interviews were designed to elicit participant experiences of the ATM program. The main topics covered included (1) experience in the money management program, (2) what clients liked or disliked about ATM, (3) ability to save money during ATM, (4) therapeutic relationship with the money manager, and (5) presence of social supports while participating in ATM.
Data Analysis Transcripts of a first set of participant interviews (n ¼ 15) were imported into NVivo 9, a software program for qualitative data management, coding and analysis (QSR International, 2010). To begin the process of coding and to establish interrater reliability, the first two authors read through each transcript and separately produced a master document of themes for each interview with highlighted quotations, then met to discuss the codes and decide on strategies for recoding documents. Initially there were 18 codes (referred to as nodes in the NVivo 8 program). The researchers then listened to
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the second set of transcribed interviews with the same participants (N ¼ 15) to see if additional themes emerged. None did, but the second interviews did clarify themes from the first set. Following this step, the third and fourth authors examined themes and representative quotations. These themes were discussed, some changes were made in terminology for themes, and consensus was reached on five themes, as discussed in the Results section below. RESULTS We identified five main themes: (1) trust, (2) financial mindfulness, (3) agency (4) addiction, and (5) absence of coercion, with significant overlap and complementarity among these themes. As no notable differences in comments were seen between individual participants who had deposited their income with the study money manager and those who had not, we do not note deposit information in introducing participant comments below. We have edited comments to eliminate repetition, but participants spoke all words quoted other than those in brackets. First names given below are pseudonyms.
1. Trust Clients interviewed almost invariably noted their trust in the money managers for this study. Although many participants felt that getting started with money management was challenging, early engagement with and development of trust with money managers may have been an important factor in their continuing participation and perceived benefits from the program. At times, trust was linked with participants’ sense that their money manager was truly interested in their lives beyond the domain of finances, as with the following two comments from a Caucasian male, Eric, in his mid 60s, with a history of polysubstance use and participation in AA, including as a sponsor: Let’s say I had a problem with my dog. They really got to know me and they would ask, you know . . . . It makes you more sociable. After we got started, I didn’t know what to expect, but as I got to know her we talked and shared some things, a trust was built up and it had nothing to do with the money management.
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Subjective Experience of Money Management 143 Other participants appeared to link trust to learning skills and being supported regarding their finances. ‘‘I had somebody backing me and showing me how to spend my money wisely and not unwisely,’’ said one. Trust may also have been a factor in facilitating participants’ ability to take risks in their efforts to make personal progress in their finances and other areas of their lives. The speakers below are a middle-aged, Caucasian female with alcohol addiction and a 30s Caucasian male, John, who had been abstinent from drugs for a few years but relapsed shortly before the study began: I asked her for help or advice and she was always there for me. I might have fell down a few times but she picked me back up. She made me chance it . . . and I got to be stronger. They helped me find courage and hope. Besides the money, about other things too. Being out and doing things.
With trust comes personal accountability, as with Janis, who is African American and in her 50s who, while a participant in the study, was also working as a peer mentor in another program: It was kind of like a check-in and it kept me accountable. It helped me to show me where everything was going, which I never looked at before. I never did that before, never budgeted.
A few participants linked trust in their money manager with lack of trust in themselves at the outset of their participation in money management. The following speaker, Anna, who is African American and in her 50s, had a long history of lending money to relatives and friends: I couldn’t help myself. So somebody had to step in and help me . . . . I trusted them with my money because I couldn’t trust myself . . . . I was spending $500 in one day . . . . Cocaine and alcohol. And I was so glad that she didn’t give me the money to do what I do with alcohol and drugs.
Participant comments, then, suggest the importance they place on trusting their money manager. One hint as to the importance of trust in regard to money management comes from Eric, who spoke, in effect, of the intimacy of one’s own money: I think [it’s] important when you’re talking about something sensitive enough, about someone’s finances, that they be allowed to form some sort of working relationship.
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2. Financial Mindfulness Participants’ increasing attention to their use of money came through strongly in the interviews. They became more mindful of the role of finances in their lives. Many spoke of learning how to spend differently through attention to the budgets they created with their money managers and through reflecting on how they had spent money in the past. Andrea, who is Caucasian and in her 50s, had a history of spending sprees and wanted to save money to move out of her slum apartment: In the beginning, the first couple of months, it was hard saying, ‘‘Money has to go here, money has to go there,’’ and then you can think about buying snacks when you are out somewhere. You don’t [usually] think about every single time you put out even 35 cents. [But] things add up, a dollar here, two dollars there, that’s where the money goes. Keeping a detailed account . . . was eye-opening for me . . . . [But] [o]nce I got into the habit of doing it, it was nothing.
Attention to spending money was often specific as to certain items or sites for spending one’s money. The first speaker is Andrea. The second is James, who, in addition to paying friends often and generously for small favors, had a habit of spending his food stamp money early in the month: I was always buying bottled water, but now I carry it with me. What I do is buy a gallon of water and fill it into small bottles . . . . [I]t’s $1.25 every time you buy a bottle. I’m in menopause. I sweat a lot. I drink a lot of water. I save a lot of money just in a week. I get $200 in food stamps every month. I can spend that in a week so they was trying to help me budget that, buying more stuff for the house, go shopping so you have food all month you know . . . I’ll go eat Italian food and spend it up in like a week. I stopped doing that. I go to Shop Rite and buy nice meat and vegetables and fruit . . . . Once in a while I still treat myself but not like before.
The next two comments are intriguing in regard to the possible longer-term impact of participation in money management. The first speaker is John, who spoke of trust, above; the second is Andrea: I took a turn for the worse after finishing the study but some of the things they had me doing stuck with me. Little things like keeping a record in my
Subjective Experience of Money Management 145 checkbook instead of trying to do it all with bank statements . . . . Running a budget with the receipts that I had paid in the last month, that sort of thing.
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Ever since I’ve been in money management my lights haven’t been turned off and my gas hasn’t been turned off and my rent always been paid and my phone always been on. Even after I left [the study].
Financial mindfulness is often linked to specific shopping and saving skills and processes, as with some of the comments above and these below from Anna, who spoke, above, on her lending habits, then Andrea, then Eric: One of my skills is to cut out coupons. I learned how to bargain shop. Instead of just going and picking up and picking up everything and not looking at the price tags, I look at the prices and I bargain shop. I’ve become very penny pinching. I buy in bulk when I can. I have a freezer and in the summer I buy and freeze things for the winter . . . . And planning ahead. Once a week I’ll cook a pot of soup put it into containers . . . . [And] I saved up and bought one good pair of boots. And it’s nice to be able to walk and not be able to get your feet wet. The first thing I do when I get my money—we switched me over to direct deposit [instead of] me paying the fee at the check cashing place. I pay my outstanding bills right off first thing, rent and utilities . . . and had some credit cards and I make sure that at least I make the minimum payments if not a few dollars more and whatever else . . . I pay those necessities for me and then what’s left is for me and my dog.
The money skills of which participants spoke were new to them in many cases. It is important to note that the skills they speak of are normative—the ‘‘kinds of things we all need to learn’’ in order to function well as adults in our society. It is also important to note that, though participants gained money skills, they were still poor and struggling. Janis, the peer mentor in her 50s, speaks of this: We tried to figure out where all my money was going to and the problem I had every month was that there wasn’t enough money at the end of the month. So trying to figure out how to juggle it.
The notion that money and one’s use of it is linked with many aspects of people’s lives is hardly earth-shattering, but clients’
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146 K. L. Serowik et al. budding awareness of those links and their processes, which we can only briefly discuss here, has not been described in money management research to date. Loaning or not loaning money to friends and associates may affect an individual’s continued contacts with those persons. Money interacts with many of the choices people make, including choices about treatment and sobriety, choices of relationships, and choices of pursuing or foregoing new opportunities. These interactions appear to complicate, as well as to suggest, the need for additional attention to the elements and processes of money management interventions.
3. Agency Another theme—that of personal agency in the sense, here, of the ability to successfully act on normative adult responsibilities and challenges—appears to be at work in the money management process for many study participants. ‘‘When you’re in recovery it’s, in a lot of ways, like you’re a kid trying to become an adult,’’ said one participant of her use of a notebook to track her spending habits. With new-found agency may come fears of failure, including fear of taking charge of one’s finances, as John talked of overcoming through his participation in the study: Finances never were easy, never will be easy for me, but I think coming here took some of the fear and dread that I had away.
A comment from Andrea, who had the goal of saving money to move out of her slumlord-owned apartment, offers one example of the ways in which a change in one’s relationship to money involves, arguably, a change in one’s agency, in this case in relation to personal health and perhaps even survival. Having high blood pressure, I’m on a restricted diet. I can’t eat anything in a can [which is] about 95% of what you get in the store. So I have to do all my cooking from scratch. [I]t’s not expensive to eat well . . . when you don’t buy the junk. Which costs money, to buy the junk. It’s not expensive to eat well.
Some speakers had patterns of loaning money to make or keep friends, to avoid confrontation, or out of an inability to put their own needs first. The corresponding ability to change that pattern
Subjective Experience of Money Management 147 is a matter of personal agency in the social world. John is the participant in this exchange: I would hang out with my friends and blow off all my money . . . . Go out drinking, playing pool . . . lending people money . . . . I stopped doing all that.
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Interviewer: Was that difficult, to stop? Participant: Yeah ‘cause I’m a nice guy, I don’t like to say no . . . . I learned now to say no. People don’t do it for me so I don’t do it for them. [J]ust pay your bills before you give money out to people . . . [the money manager] helped me understand that I wasn’t in the position where I could look out for others. She was basically saying, ‘‘Put yourself first.’’
Although participants did, indeed, learn new spending skills, it is important to note that one’s old spending patterns may be associated with cultural or situational factors, such as with people who are homeless looking out for each other on the street (Rowe, 1999). These patterns may need to change, as with people who are homeless moving into apartments and learning that they can’t let their friends stay with them, but the changes are made with some ambivalence and acknowledgement that the prior mode (e.g., sharing funds) was appropriate to the prior lifestyle.
4. Addiction Addiction is a different category of theme than those above in that it was a focus of participation in the study, and money managers routinely discussed substance use and encouraged recovery efforts and participation in AA and NA. Thus, issues of addiction appear across all other identified themes. Still, it is useful to examine participants’ comments on substance use in the context of money management. Eric spoke of the link between money management and substance use: For people like me with mental health issues, which can be a combination of psychiatric and substance abuse . . . [an early sign] when you start to relapse is the ability to manage your money . . . . Some of the times you go on spending sprees, like I do. I go out and buy things I really don’t need but I just do it and eventually my money starts being spent on substances. So [money management] helped and I’m still sober and that’s the bottom line for me.
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Some participants, including Eric, linked money management to counseling on recovery from addiction: We talked about my how many AA meetings I was making and we had a plan . . . . I wasn’t here to learn how to manage money I didn’t come here for that. I was here to stay sober and keep my head straight. This was offered to me as another tool . . . . It starts with money, but here’s the situation . . . . We set some goals, ‘‘Are you going to AA?’’ ‘‘How many AA meetings do you go to?’’ We discussed all those things and where I was at so that led into more conversations. You start with money management because that’s what the program was about but as that progressed, [my] focus broadened . . . and I explored my own thoughts. I took advantage of it to explore managing other things in my life. It was the initial stepping stone.
5. Noncoercion A final theme—noncoercion—is one that is notable for the lack of participant comment, except for one participant, James, who spoke favorably of his (study) money manager as compared with a payee with whom he had worked in the past: I felt like he was basically the boss over my money. He was always saying, ‘‘You’re the boss over your own money,’’ but I felt like he was the boss . . . . E [would] say, ‘‘Well, I tell you to pay your bills but if you don’t want to pay it, it’s up to you.’’ I would . . . take her advice.
Study participants, including those who voluntarily deposited money with their money manager and those who maintained sole power over their money, did not speak of, or allude to, coercion in the participant-money manager relationship or in money managers’ suggestions about their spending habits. This fact is no doubt related to the voluntary nature of participation in the study and to the option of continuing to maintain control over one’s money. Still, the nature of the client–money manager relationship and the work done through it may provide some hints regarding enhancing a sense of agency and, perhaps, eventual greater control over finances for persons in involuntary (conservator or representative payee) interventions. DISCUSSION In this first survey of clients in a voluntary money management program, participants described liking and feeling helped by many
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Subjective Experience of Money Management 149 components of it. Clients raised issues about ATM that relate more to financial discussion than to counseling in general. Counseling that focused on finances took some getting used to, even among people who were accustomed to sharing sensitive issues as part of ongoing psychiatric treatment. The novelty of discussing finances was also apparent in the fact that clients’ financial mindfulness was new to them—they thought more often and more reflectively about finances in day-to-day financial and other transactions. Clients’ emphasis on trust was also related to money management; although trust is an important part of any counseling relationship, it is not typically the main concern raised when clients are asked to rate their therapists in other treatments (Horvath & Greenberg, 1986). Clients’ emphasis on having a trustworthy therapist appeared to be related to the sensitivity of discussing financial issues. Clients appeared to provide valid reports of their experience of ATM, and did not give the nonspecific comments one might expect if clients felt some pressure to praise the program. As opposed to feelings of coercion often described by people in involuntary payee arrangements, clients in ATM felt a sense of agency in controlling their own finances and asserting their ability to make spending decisions. This suggests that money management is not inherently coercive, and can be empowering when a money manager explicitly promotes autonomy. In ATM, the client makes the financial decisions with guidance from the money manager. This study has important implications for the design of money management programs. Because of the importance of trust in fiduciary relationships, money management programs should include features specifically designed to foster trust between the money manager and client. Trust can be fostered by providing clients with a clear treatment contract that spells out the role and responsibilities of the client and money manager. Providing clients frequent, understandable financial feedback—receipts, balances and budgets—can also help facilitate trust. Such feedback, an important part of part of the parent study, may have contributed to clients’ taking an active role in understanding and planning their expenditures. Money management programs should explicitly encourage clients to become more mindful of the role of finances in their day-to-day lives. Although theoretically there might be more anxiety associated with thinking about how one spends money, in practice clients found it empowering to think about their expenditures and were proud of the changes they made.
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150 K. L. Serowik et al. The literature has shown that there is substantial variability in the extent to which different states (Rosen, McMahon, & Rosenheck, 2007), and even different treatment programs within a state implement representative payee assignment, and the implementation of any money management program is likely to depend on aspects of the treating facility (Moser & Bond, 2009). Providing money management counseling that fosters trust, financial mindfulness, and a sense of agency is certainly consistent with the goals of the recovery movement (Jacobson & Greenley, 2001) in that recovery emphasizes client partnership in directing treatment and improvement in quality of life and not just symptoms. However, implementation of a money management program is not simple. A voluntary money management program requires staff training in counseling and in the management of an account with client funds (materials available for download at www.behavior change.yale.edu). Our data suggest that another barrier to the establishment of a voluntary money management program is the initial reluctance of clients to discuss finances with a therapist. With a focus on building trust and working collaboratively with the client, a money management program is more likely to be accepted. The relationship of a voluntary money management program to existing payee programs may complicate their adoption because of possible confusion between the voluntary and involuntary programs. It is important that agencies consider the duration of voluntary money management interventions, how the interventions are sequenced and fitted into the other services offered, and how money management programs are staffed.
Limitations Most ATM counseling was delivered by a single money manager, and study results were from only 15 participants. It is possible that different themes would have emerged if more client-money manager pairs had been studied. It is also possible that these participants, by virtue of being at the mental health center 1 year after the parent study and being willing to participate in the qualitative study, were more inclined to view money management favorably than those who did not participate. It is also possible that participants selectively remembered the aspects of the program they liked, as there is some benefit to remembering past efforts in a favorable light (e.g., Lyubomirsky & Tucker, 1998; Zhang & Howell,
Subjective Experience of Money Management 151 2011). Finally, it is unknown whether the experience of participants in this research study will be representative of experiences in future settings with other staff, clientele, and cultures.
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CONCLUSION This qualitative study suggests a number of benefits of voluntary money management, including client engagement in their own finances, client satisfaction with voluntary and therapeutic money management, and financial skills building for clients. These findings were accompanied with a reduction in cocaine use among those who participated in the ATM group, compared with the control group (Rosen et al., 2010). Future research should explore the benefits as well as difficulties associated with this form of financial assistance for persons with mental illnesses. It is also important to consider other stakeholders, such as family members, clinicians who work alongside money managers, and administrators who oversee the money management programs. Improved money management skills can translate into a marginal improvement in one’s economic standing and can assist those living with mental illness and their communities within the broader context of social and economic poverty. REFERENCES Angell, B., Martinez, N. I., Mahoney, C. A., & Corrigan, P. W. (2007). Payeeship, financial leverage, and client-provider relationship. Psychiatric Services, 58(3), 365–372. Bond, G. R., Drake, R. E., Becker, D. R., & Mueser, K. T. (1999). Effectiveness of psychiatric rehabilitation approaches for employment of people with severe mental illness. Journal of Disability Policy Studies, 10(1), 18–52. Brotman, A. W., & Muller, J. J. (1990). The therapist as representative payee. Hospital & Community Psychiatry, 41(2), 167–171. Conrad, K. J., Lutz, G., Matters, M. D., Donner, L., Clark, E., & Lynch, P. (2006). Randomized trial of psychiatric care with representative payeeship for persons with serious mental illness. Psychiatric Services, 57(2), 197–204. Dixon, L., Turner, J., Krauss, N., Scott, J., & McNary, S. (1999). Case managers’ and clients’ perspectives on a representative payee program. Psychiatric Services, 50(6), 781–786. Estroff, S. E., Patrick, D. L., Zimmer, C. R., & Lachicotte, W. S. (1997). Pathways to disability income among persons with severe persistent psychiatric disorders. Milbank Quarterly, 75(4), 495–532.
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152 K. L. Serowik et al. Frank, R. G., & Glied, S. (2006). Better but not well: Mental heath policy in the United States since 1950. Baltimore, MD: John Hopkins University Press. Goldfinger, S. M., Schutt, R. K., Tolomiczenko, G. S., Seidman, L., Penk, W. E., Turner, W., & Caplan, B. (1999). Housing placement and subsequent days homeless among formerly homeless adults with mental illness. Psychiatric Services, 50(5), 674–679. Haranahan, P., Luchins, D. J., Savage, C., Patrick, G., Roberts, D., & Conrad, K. J. (2002). Representative payee programs for persons with mental illness in Illinois. Psychiatric Services, 53(2), 190–194. Horvath, A. O., & Greenberg, L. (1986). The development of the Working Alliance Inventory. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 529–556). New York: Guilford. Jacobson, N., & Greenley, D. (2001). What is recovery? A conceptual model and explication. Psychiatric Services, 52(4), 482–485. Jenkins, R., Bhugra, D., Bebbington, P., Brugha, T., Farrell, M., Coid, J., et al. (2008). Debt, income and mental disorder in the general population. Psychological Medicine, 38, 1485–1493. Kertesz, S. G., & Weiner, S. J. (2009). Housing the chronically homeless. JAMA, 301(17), 1822–1824. Lipton, F. R., Siegel, C., Hannigan, A., Samuels, J., & Baker, S. (2000). Tenure in supportive housing for homeless persons with severe mental illness. Psychiatric Services, 51(4), 479–486. Luchins, D. J., Hanrahan, P., Conrad, K. J., Savage, C., Matters, M. D., & Shinderman, M. (1998). An agency-based representative payee program and improved community tenure of persons with mental illness. Psychiatric Services, 49(9), 1218–1222. Lyubomirsky, S., & Tucker, K. L. (1998). Implications of individual differences in subjective happiness for perceiving, interpreting, and thinking about life events. Motivation and Emotion, 22(2), 155–186. Moser, L. L., & Bond, G. R. (2009). Scope of agency control: Assertive community treatment teams’ supervision of consumers. Psychiatric Services, 60(7), 922–928. Neale, M. S., & Rosenheck, R. A. (2000). Therapeutic limit setting in an assertive community treatment program. Psychiatric Services, 51(4), 499–505. NVivo (Version 9). QSR International (2010). http://www.qsrinternational.com. Ries, R. K., & Comtois, K. A. (1997). Managing disability benefits as part of treatment for persons with severe mental illness and comorbid drug=alcohol disorders. American Journal on Addictions, 6(4), 330–338. Ries, R. K., & Dyck, D. G. (1997). Representative payee practices of community mental health centers in Washington state. Psychiatric Services, 48(6), 811–814. Rosen, M. I. (2011). The ‘‘check effect’’ reconsidered. Addiction, 106(6), 1071–1077. Rosen, M., Bailey, M., & Rosenheck, R. R. (2003). Alcohol & drug abuse: Principles of money management as a therapy for addiction. Psychiatric Services, 54(2), 171–173. Rosen, M. I., Desai, R., Bailey, M., Davidson, L., & Rosenheck, R. (2001). Consumer experience with payeeship provided by a community mental health center. Psychiatric Rehabilitation Journal, 25(2), 190–195. Rosen, M. I., McMahon, T. J., & Rosenheck, R. (2007). Does assigning a representative payee reduce substance abuse? Drug and Alcohol Dependence, 86(2–3), 115–122. Rosen, M. I., Rosenheck, R. A., Shaner, A., Eckman, T., Gamache, G., & Krebs, C. (2002a). Veterans who may need a payee to prevent misuse of funds for drugs. Psychiatric Services, 53, 995–1000.
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Subjective Experience of Money Management 153 Rosen, M. I., Rosenheck, R. A., Shaner, A. L., Eckman, T., Gamache, R., & Krebs, C. (2002b). Substance abuse and the need for money management assistance among psychiatric inpatients. Drug and Alcohol Dependence, 67, 331–334. Rosen, M. I., Rounsaville, B. J., Ablondi, K., Black, A. C., & Rosenheck, R. A. (2010). Advisor-teller money manager (ATM) therapy for substance use disorders. Psychiatric Services, 67, 707–713. Rowe, M. (1999). Crossing the border: Encounters between homeless people and outreach workers. Berkeley: University of California Press. Shaner, A., Tucker, D. E., Roberts, L. J., & Eckman, T. A. (1999). Disability income, cocaine use, and contingency management among patients with cocaine dependence and schizophrenia. In S. T. Higgins & K. Silverman (Eds.), Motivating behavior change among illicit–drug abusers: Research on contingency management interventions (pp. 95–121). Washington, DC: American Psychological Association. Social Security Administration. (2006). Annual statistical report on the Social Security Disability Insurance Program 2005. Retrieved from http://www.socialsecurity. gov/policy/docs/statcomps/di_asr/2005/ Social Security Administration. (2007). SSI Annual Statistical Report, 2005. Retrieved from http://www.socialsecurity.gov/policy/docs/statcomps/ssi_asr/2005 Tsemberis, S., & Eisenberg, R. F. (2000). Pathways to housing: Supported housing for street–dwelling homeless individuals with psychiatric disabilities. Psychiatric Services, 51(4), 487–493. Zhang, J. W., & Howell, R. T. (2011). Do time perspectives predict unique variance in life satisfaction beyond personality traits? Personality and Individual Differences, 50, 1261–1266.
American Journal of Psychiatric Rehabilitation Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uapr20
Subjective Experiences of Clients in a Voluntary Money Management Program Kristin L. Serowik M.A. a
a c
a
, Chyrell D. Bellamy ,
Michael Rowe & Marc I. Rosen
b c
a
Department of Psychiatry , Yale University School of Medicine , New Haven , Connecticut , USA b
Department of Psychiatry , Yale University School of Medicine, New Haven, Connecticut , West Haven , Connecticut , USA c
VA Connecticut Healthcare System , West Haven , Connecticut , USA Published online: 29 May 2013.
To cite this article: Kristin L. Serowik M.A. , Chyrell D. Bellamy , Michael Rowe & Marc I. Rosen (2013) Subjective Experiences of Clients in a Voluntary Money Management Program, American Journal of Psychiatric Rehabilitation, 16:2, 136-153, DOI: 10.1080/15487768.2013.789699 To link to this article: http://dx.doi.org/10.1080/15487768.2013.789699
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American Journal of Psychiatric Rehabilitation, 16: 136–153, 2013 Copyright # Taylor & Francis Group, LLC ISSN: 1548-7768 print=1548-7776 online DOI: 10.1080/15487768.2013.789699
Subjective Experiences of Clients in a Voluntary Money Management Program Kristin L. Serowik Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA; VA Connecticut Healthcare System, West Haven, Connecticut, USA Chyrell D. Bellamy and Michael Rowe Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA Marc I. Rosen Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut, USA A large proportion of people diagnosed with mental illnesses have difficulty managing their money, and therefore many psychiatric treatments involve providing money management assistance. However, little is known about the subjective experience of having a money manager, and extant literature is restricted to people forced to work with a representative payee or conservator. In this study, fifteen people were interviewed about their experience receiving a voluntary money management intervention designed to
This work was supported in part by grants DA12952, DA025613, and MH083394 to Dr. Rosen. The authors would like to thank Lisa Fenton, PsyD, and Anne Black, PhD, for conducting the qualitative interviews. Address correspondence to Kristin L. Serowik, M.A., Department of Psychiatry, Yale University School of Medicine, 34 Park St., New Haven, CT 06519, USA. E-mail: [email protected]
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minimize substance use. Clients emphasized the importance of trusting the money manager, financial mindfulness (an enhanced awareness of the financial transactions in clients’ day-to-day lives), agency over their own affairs, and addiction. In contrast to evaluations of people assigned representative payees or conservators, there was little mention of feeling coerced. These findings suggest that money management programs can address client concerns by building trust, relating budgeting to clients’ day-to-day lives, and encouraging clients’ control over their own affairs. Keywords: Money management; Poverty; Serious mental illness; Social Security; Substance use
The lives of many people with severe and persistent mental illnesses are made harder by poverty. (Frank & Glied, 2006). Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) provide funds for disabled people to meet their basic needs, albeit at the cost of their adopting a self-identification as ‘‘disabled’’ (Estroff, Patrick, Zimmer, & Lachicotte, 1997). SSI and SSDI also facilitate access to other resources such as case management, health insurance, housing assistance, and vocational support (Frank & Glied, 2006). A substantial proportion of people disabled by severe and persistent mental illness have unmet money management needs. A high proportion have been found to be financially victimized (Conrad et al., 2006), unable to meet basic needs (Rosen et al., 2002a), extensively indebted (Jenkins et al., 2008), and frequently homeless or in psychiatric hospitals because of mismanaged funds (Hanrahan et al., 2002). Problems managing funds are especially pronounced among people with mental illness who also abuse substances (Rosen et al., 2002b). Substance abuse reflects money mismanagement when drugs and alcohol are purchased with SSI and SSDI benefits; sometimes drugs are purchased at the same time of the month the disability checks are received (Rosen, 2011). Clients who relapse to substance use are at heightened risk of losing their housing (Goldfinger et al., 1999; Lipton, Siegel, Hannigan, Samuels, & Baker, 2000). In part because substance abuse can lead to homelessness, substance use was the most common reason cited for assigning a representative payee among surveyed case managers (Luchins et al., 1998). To address client difficulties with their finances, many psychiatric treatments and psychosocial rehabilitation programs involve
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138 K. L. Serowik et al. providing money management assistance. Examples include supportive housing (Kertesz & Weiner, 2009; Tsemberis & Eisenberg, 2000), supportive employment (Bond, Drake, Becker, & Mueser, 1999), and assertive community treatment programs (Neale & Rosenheck, 2000). One particular widely employed money management intervention is the administrative assignment of a representative payee to store, manage, and dispense beneficiary funds. Approximately 30% of beneficiaries receiving SSI or SSDI, for example, are mandated to have a representative payee (Social Security Administration, 2006; 2007). Fortunately, assignment of representative payees when those payees are affiliated with treatment facilities has been associated with a variety of benefits including higher attendance at outpatient treatment (Ries & Comtois, 1997), better client-reported quality of life, a decrease in alcohol and illicit drug use, and better management of funds (Conrad et al., 2006; Rosen, 2011). Money management is increasingly considered to be a therapeutic intervention (Rosen, Bailey, & Rosenheck, 2003). Descriptions of clients’ subjective experience of money management interventions have been limited to clients who have been assigned representative payees, usually those affiliated with clinical programs. Dixon and colleagues (Dixon, Turner, Krauss, Scott, & McNary, 1999) interviewed 54 clients and their case managers in a payee program based at a community mental health center concerning client attitudes toward the payee program. Overall satisfaction with the program was high, but the most satisfied clients were those who had been in the program for over a year. These high satisfaction ratings may have been associated with selective retention of satisfied clients. Tension in the client-payee relationship was reflected in the fact that case managers for 44% of clients reported that their client had been verbally abusive in connection with representative payee activities (Dixon et al., 1999). In a series of case reports, Brotman and Muller (1990) described the potential for boundary confusion when the client’s payee was also the client’s clinician. Some clients became agitated because of feeling engulfed, controlled, or overly dependent on the payee-therapist. Another explanation that has been offered for tension between client and payee-clinicians is that clients may feel that their clinician misused the financial control of being a payee to force the client to comply with treatment (Angell, Martinez, Mahoney, & Corrigan, 2007; Hanrahan et al., 2002). A substantial minority of clients for whom
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Subjective Experience of Money Management 139 money manager and clinician functions are performed by different people (Shaner, Tucker, Roberts, & Eckman, 1999; Ries & Dyck, 1997) also report feeling coerced by their representative payees, although most clients report high overall satisfaction with the payee arrangement (Rosen, Desai, Bailey, Davidson, & Rosenheck, 2001). Clients’ experience of having a representative payee is influenced by the fact that payee assignment is typically recommended by a third party, mandated by an outside agency (the Social Security Administration), and involves loss of legal and fiduciary autonomy. It is not known whether the issues described by assigned representative payees are inherent to and characteristic of all money management interventions, voluntary or not. The study we report in this article was undertaken to address this gap in the literature by asking clients their experience of voluntary money management intervention. We hypothesized that a voluntary money management program would be experienced empowering rather than patronizing because it offered clients the opportunity to use money to further personal goals. Clients who had been assigned to a voluntary money management intervention in a randomized clinical trial were sought after the study ended for qualitative interviews concerning their experience of the money management intervention. METHOD
Participants In the parent clinical trial, participants with a history of cocaine or alcohol abuse who were in psychiatric treatment at an urban community mental health center were invited to participate in a 9-month clinical trial comparing a money management intervention focused on substance abuse counseling called advisor-teller money manager (ATM) (Rosen et al., 2003), with a control condition receiving financial education (details about study in Rosen, Rounsaville, Ablondi, Black, & Rosenheck, 2010). ATM participants were encouraged to have their checks sent directly to the money manager and deposited into a pooled account. The money manager paid clients’ bills directly and gave the client disbursements for budgeted expenses. Participants in ATM met with the money manager weekly for financial and substance use counseling. As part of the financial counseling, the money manager planned monthly budgets with clients and
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140 K. L. Serowik et al. taught each client how to track expenses. Participants were asked to link their spending to an abstinence-related activity during the upcoming week. A breathalyzer and on-site urine toxicology screen were analyzed at the weekly sessions, and substance use episodes were reviewed to plan alternative activities and expenditures. In the parent clinical trial, participation in ATM was extensive, with clients attending an average of 22.5 sessions during the 36-week intervention and many opting to store their funds with the money manager. Of those assigned to ATM, 33% had funds deposited to the pooled account, 35% had their checkbook stored by the money manager, and 13% had both their funds and checkbook stored by the money manager. Compared with the control group, ATM participants used less cocaine over time. There was no difference in the proportion of patients attending nonstudy treatment by group, indicating that ATM neither facilitated treatment at the mental health center nor substituted for it. There was a serious adverse event in which a study participant in ATM assaulted the money manager when she did not have his money, and another participant became agitated when he was assigned a conservator. Approximately 1 year after completion of the clinical trial, persons who had been randomly assigned to the ATM counseling were recruited by flyers posted at the mental health center and by asking their clinicians to inform them of this qualitative study. Because recruitment was at the mental health center, only participants who were in treatment at the mental health center 1 year after the parent study learned about the study. Sixteen of the 47 individuals in the ATM counseling of the parent clinical trial were approached to undergo interviews, and 15 were enrolled. Neither the assaultive nor the agitated participants from the parent trial enrolled in this interview study. All 15 study participants were receiving SSI and=or SSDI. Their mean age was 44 (SD ¼ 9.4) and mean GAF score was 42 (SD ¼ 5). Altogether, 56% of participants were Black, 28% were White, and 16% Hispanic. Fifty percent had a diagnosis of bipolar disorder; 28.6% had schizophrenia or a similar disorder; 21.4%, major depression; and 6.7%, psychosis not otherwise specified. Forty percent reported cocaine use in the previous 28 days and 53.3% reported using alcohol in the prior 28 days. The 15 ATM participants who took part in the qualitative interviews were compared with the 32 ATM participants who did not.
Subjective Experience of Money Management 141 The only significant difference between the groups was that the qualitative study participants had attended more therapy sessions (M ¼ 30.6, SD ¼ 18.07) than did the ATM participants who were not in the qualitative study (M ¼ 18.69, SD ¼ 12.7), t(45) ¼ 2.61, p < .01.
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Procedures Each participant completed two separate in-depth interviews a week apart with different interviewers. The interviewers included a psychiatrist (M.I.R.) and two psychologists who had experience working with disenfranchised populations. After informed consent was obtained, participants were interviewed in an office at the mental health center. All interviews were audiotaped, and the first interviews were transcribed and analyzed. Second interviews were conducted to supplement the initial interviews, using the same prompts but a different interviewer.
Materials The interviewer was given a list of prompt questions to elicit the clients’ views about their participation in the ATM program. (Interview prompts are available on request.) The interviews were designed to elicit participant experiences of the ATM program. The main topics covered included (1) experience in the money management program, (2) what clients liked or disliked about ATM, (3) ability to save money during ATM, (4) therapeutic relationship with the money manager, and (5) presence of social supports while participating in ATM.
Data Analysis Transcripts of a first set of participant interviews (n ¼ 15) were imported into NVivo 9, a software program for qualitative data management, coding and analysis (QSR International, 2010). To begin the process of coding and to establish interrater reliability, the first two authors read through each transcript and separately produced a master document of themes for each interview with highlighted quotations, then met to discuss the codes and decide on strategies for recoding documents. Initially there were 18 codes (referred to as nodes in the NVivo 8 program). The researchers then listened to
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the second set of transcribed interviews with the same participants (N ¼ 15) to see if additional themes emerged. None did, but the second interviews did clarify themes from the first set. Following this step, the third and fourth authors examined themes and representative quotations. These themes were discussed, some changes were made in terminology for themes, and consensus was reached on five themes, as discussed in the Results section below. RESULTS We identified five main themes: (1) trust, (2) financial mindfulness, (3) agency (4) addiction, and (5) absence of coercion, with significant overlap and complementarity among these themes. As no notable differences in comments were seen between individual participants who had deposited their income with the study money manager and those who had not, we do not note deposit information in introducing participant comments below. We have edited comments to eliminate repetition, but participants spoke all words quoted other than those in brackets. First names given below are pseudonyms.
1. Trust Clients interviewed almost invariably noted their trust in the money managers for this study. Although many participants felt that getting started with money management was challenging, early engagement with and development of trust with money managers may have been an important factor in their continuing participation and perceived benefits from the program. At times, trust was linked with participants’ sense that their money manager was truly interested in their lives beyond the domain of finances, as with the following two comments from a Caucasian male, Eric, in his mid 60s, with a history of polysubstance use and participation in AA, including as a sponsor: Let’s say I had a problem with my dog. They really got to know me and they would ask, you know . . . . It makes you more sociable. After we got started, I didn’t know what to expect, but as I got to know her we talked and shared some things, a trust was built up and it had nothing to do with the money management.
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Subjective Experience of Money Management 143 Other participants appeared to link trust to learning skills and being supported regarding their finances. ‘‘I had somebody backing me and showing me how to spend my money wisely and not unwisely,’’ said one. Trust may also have been a factor in facilitating participants’ ability to take risks in their efforts to make personal progress in their finances and other areas of their lives. The speakers below are a middle-aged, Caucasian female with alcohol addiction and a 30s Caucasian male, John, who had been abstinent from drugs for a few years but relapsed shortly before the study began: I asked her for help or advice and she was always there for me. I might have fell down a few times but she picked me back up. She made me chance it . . . and I got to be stronger. They helped me find courage and hope. Besides the money, about other things too. Being out and doing things.
With trust comes personal accountability, as with Janis, who is African American and in her 50s who, while a participant in the study, was also working as a peer mentor in another program: It was kind of like a check-in and it kept me accountable. It helped me to show me where everything was going, which I never looked at before. I never did that before, never budgeted.
A few participants linked trust in their money manager with lack of trust in themselves at the outset of their participation in money management. The following speaker, Anna, who is African American and in her 50s, had a long history of lending money to relatives and friends: I couldn’t help myself. So somebody had to step in and help me . . . . I trusted them with my money because I couldn’t trust myself . . . . I was spending $500 in one day . . . . Cocaine and alcohol. And I was so glad that she didn’t give me the money to do what I do with alcohol and drugs.
Participant comments, then, suggest the importance they place on trusting their money manager. One hint as to the importance of trust in regard to money management comes from Eric, who spoke, in effect, of the intimacy of one’s own money: I think [it’s] important when you’re talking about something sensitive enough, about someone’s finances, that they be allowed to form some sort of working relationship.
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2. Financial Mindfulness Participants’ increasing attention to their use of money came through strongly in the interviews. They became more mindful of the role of finances in their lives. Many spoke of learning how to spend differently through attention to the budgets they created with their money managers and through reflecting on how they had spent money in the past. Andrea, who is Caucasian and in her 50s, had a history of spending sprees and wanted to save money to move out of her slum apartment: In the beginning, the first couple of months, it was hard saying, ‘‘Money has to go here, money has to go there,’’ and then you can think about buying snacks when you are out somewhere. You don’t [usually] think about every single time you put out even 35 cents. [But] things add up, a dollar here, two dollars there, that’s where the money goes. Keeping a detailed account . . . was eye-opening for me . . . . [But] [o]nce I got into the habit of doing it, it was nothing.
Attention to spending money was often specific as to certain items or sites for spending one’s money. The first speaker is Andrea. The second is James, who, in addition to paying friends often and generously for small favors, had a habit of spending his food stamp money early in the month: I was always buying bottled water, but now I carry it with me. What I do is buy a gallon of water and fill it into small bottles . . . . [I]t’s $1.25 every time you buy a bottle. I’m in menopause. I sweat a lot. I drink a lot of water. I save a lot of money just in a week. I get $200 in food stamps every month. I can spend that in a week so they was trying to help me budget that, buying more stuff for the house, go shopping so you have food all month you know . . . I’ll go eat Italian food and spend it up in like a week. I stopped doing that. I go to Shop Rite and buy nice meat and vegetables and fruit . . . . Once in a while I still treat myself but not like before.
The next two comments are intriguing in regard to the possible longer-term impact of participation in money management. The first speaker is John, who spoke of trust, above; the second is Andrea: I took a turn for the worse after finishing the study but some of the things they had me doing stuck with me. Little things like keeping a record in my
Subjective Experience of Money Management 145 checkbook instead of trying to do it all with bank statements . . . . Running a budget with the receipts that I had paid in the last month, that sort of thing.
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Ever since I’ve been in money management my lights haven’t been turned off and my gas hasn’t been turned off and my rent always been paid and my phone always been on. Even after I left [the study].
Financial mindfulness is often linked to specific shopping and saving skills and processes, as with some of the comments above and these below from Anna, who spoke, above, on her lending habits, then Andrea, then Eric: One of my skills is to cut out coupons. I learned how to bargain shop. Instead of just going and picking up and picking up everything and not looking at the price tags, I look at the prices and I bargain shop. I’ve become very penny pinching. I buy in bulk when I can. I have a freezer and in the summer I buy and freeze things for the winter . . . . And planning ahead. Once a week I’ll cook a pot of soup put it into containers . . . . [And] I saved up and bought one good pair of boots. And it’s nice to be able to walk and not be able to get your feet wet. The first thing I do when I get my money—we switched me over to direct deposit [instead of] me paying the fee at the check cashing place. I pay my outstanding bills right off first thing, rent and utilities . . . and had some credit cards and I make sure that at least I make the minimum payments if not a few dollars more and whatever else . . . I pay those necessities for me and then what’s left is for me and my dog.
The money skills of which participants spoke were new to them in many cases. It is important to note that the skills they speak of are normative—the ‘‘kinds of things we all need to learn’’ in order to function well as adults in our society. It is also important to note that, though participants gained money skills, they were still poor and struggling. Janis, the peer mentor in her 50s, speaks of this: We tried to figure out where all my money was going to and the problem I had every month was that there wasn’t enough money at the end of the month. So trying to figure out how to juggle it.
The notion that money and one’s use of it is linked with many aspects of people’s lives is hardly earth-shattering, but clients’
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146 K. L. Serowik et al. budding awareness of those links and their processes, which we can only briefly discuss here, has not been described in money management research to date. Loaning or not loaning money to friends and associates may affect an individual’s continued contacts with those persons. Money interacts with many of the choices people make, including choices about treatment and sobriety, choices of relationships, and choices of pursuing or foregoing new opportunities. These interactions appear to complicate, as well as to suggest, the need for additional attention to the elements and processes of money management interventions.
3. Agency Another theme—that of personal agency in the sense, here, of the ability to successfully act on normative adult responsibilities and challenges—appears to be at work in the money management process for many study participants. ‘‘When you’re in recovery it’s, in a lot of ways, like you’re a kid trying to become an adult,’’ said one participant of her use of a notebook to track her spending habits. With new-found agency may come fears of failure, including fear of taking charge of one’s finances, as John talked of overcoming through his participation in the study: Finances never were easy, never will be easy for me, but I think coming here took some of the fear and dread that I had away.
A comment from Andrea, who had the goal of saving money to move out of her slumlord-owned apartment, offers one example of the ways in which a change in one’s relationship to money involves, arguably, a change in one’s agency, in this case in relation to personal health and perhaps even survival. Having high blood pressure, I’m on a restricted diet. I can’t eat anything in a can [which is] about 95% of what you get in the store. So I have to do all my cooking from scratch. [I]t’s not expensive to eat well . . . when you don’t buy the junk. Which costs money, to buy the junk. It’s not expensive to eat well.
Some speakers had patterns of loaning money to make or keep friends, to avoid confrontation, or out of an inability to put their own needs first. The corresponding ability to change that pattern
Subjective Experience of Money Management 147 is a matter of personal agency in the social world. John is the participant in this exchange: I would hang out with my friends and blow off all my money . . . . Go out drinking, playing pool . . . lending people money . . . . I stopped doing all that.
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Interviewer: Was that difficult, to stop? Participant: Yeah ‘cause I’m a nice guy, I don’t like to say no . . . . I learned now to say no. People don’t do it for me so I don’t do it for them. [J]ust pay your bills before you give money out to people . . . [the money manager] helped me understand that I wasn’t in the position where I could look out for others. She was basically saying, ‘‘Put yourself first.’’
Although participants did, indeed, learn new spending skills, it is important to note that one’s old spending patterns may be associated with cultural or situational factors, such as with people who are homeless looking out for each other on the street (Rowe, 1999). These patterns may need to change, as with people who are homeless moving into apartments and learning that they can’t let their friends stay with them, but the changes are made with some ambivalence and acknowledgement that the prior mode (e.g., sharing funds) was appropriate to the prior lifestyle.
4. Addiction Addiction is a different category of theme than those above in that it was a focus of participation in the study, and money managers routinely discussed substance use and encouraged recovery efforts and participation in AA and NA. Thus, issues of addiction appear across all other identified themes. Still, it is useful to examine participants’ comments on substance use in the context of money management. Eric spoke of the link between money management and substance use: For people like me with mental health issues, which can be a combination of psychiatric and substance abuse . . . [an early sign] when you start to relapse is the ability to manage your money . . . . Some of the times you go on spending sprees, like I do. I go out and buy things I really don’t need but I just do it and eventually my money starts being spent on substances. So [money management] helped and I’m still sober and that’s the bottom line for me.
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Some participants, including Eric, linked money management to counseling on recovery from addiction: We talked about my how many AA meetings I was making and we had a plan . . . . I wasn’t here to learn how to manage money I didn’t come here for that. I was here to stay sober and keep my head straight. This was offered to me as another tool . . . . It starts with money, but here’s the situation . . . . We set some goals, ‘‘Are you going to AA?’’ ‘‘How many AA meetings do you go to?’’ We discussed all those things and where I was at so that led into more conversations. You start with money management because that’s what the program was about but as that progressed, [my] focus broadened . . . and I explored my own thoughts. I took advantage of it to explore managing other things in my life. It was the initial stepping stone.
5. Noncoercion A final theme—noncoercion—is one that is notable for the lack of participant comment, except for one participant, James, who spoke favorably of his (study) money manager as compared with a payee with whom he had worked in the past: I felt like he was basically the boss over my money. He was always saying, ‘‘You’re the boss over your own money,’’ but I felt like he was the boss . . . . E [would] say, ‘‘Well, I tell you to pay your bills but if you don’t want to pay it, it’s up to you.’’ I would . . . take her advice.
Study participants, including those who voluntarily deposited money with their money manager and those who maintained sole power over their money, did not speak of, or allude to, coercion in the participant-money manager relationship or in money managers’ suggestions about their spending habits. This fact is no doubt related to the voluntary nature of participation in the study and to the option of continuing to maintain control over one’s money. Still, the nature of the client–money manager relationship and the work done through it may provide some hints regarding enhancing a sense of agency and, perhaps, eventual greater control over finances for persons in involuntary (conservator or representative payee) interventions. DISCUSSION In this first survey of clients in a voluntary money management program, participants described liking and feeling helped by many
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Subjective Experience of Money Management 149 components of it. Clients raised issues about ATM that relate more to financial discussion than to counseling in general. Counseling that focused on finances took some getting used to, even among people who were accustomed to sharing sensitive issues as part of ongoing psychiatric treatment. The novelty of discussing finances was also apparent in the fact that clients’ financial mindfulness was new to them—they thought more often and more reflectively about finances in day-to-day financial and other transactions. Clients’ emphasis on trust was also related to money management; although trust is an important part of any counseling relationship, it is not typically the main concern raised when clients are asked to rate their therapists in other treatments (Horvath & Greenberg, 1986). Clients’ emphasis on having a trustworthy therapist appeared to be related to the sensitivity of discussing financial issues. Clients appeared to provide valid reports of their experience of ATM, and did not give the nonspecific comments one might expect if clients felt some pressure to praise the program. As opposed to feelings of coercion often described by people in involuntary payee arrangements, clients in ATM felt a sense of agency in controlling their own finances and asserting their ability to make spending decisions. This suggests that money management is not inherently coercive, and can be empowering when a money manager explicitly promotes autonomy. In ATM, the client makes the financial decisions with guidance from the money manager. This study has important implications for the design of money management programs. Because of the importance of trust in fiduciary relationships, money management programs should include features specifically designed to foster trust between the money manager and client. Trust can be fostered by providing clients with a clear treatment contract that spells out the role and responsibilities of the client and money manager. Providing clients frequent, understandable financial feedback—receipts, balances and budgets—can also help facilitate trust. Such feedback, an important part of part of the parent study, may have contributed to clients’ taking an active role in understanding and planning their expenditures. Money management programs should explicitly encourage clients to become more mindful of the role of finances in their day-to-day lives. Although theoretically there might be more anxiety associated with thinking about how one spends money, in practice clients found it empowering to think about their expenditures and were proud of the changes they made.
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150 K. L. Serowik et al. The literature has shown that there is substantial variability in the extent to which different states (Rosen, McMahon, & Rosenheck, 2007), and even different treatment programs within a state implement representative payee assignment, and the implementation of any money management program is likely to depend on aspects of the treating facility (Moser & Bond, 2009). Providing money management counseling that fosters trust, financial mindfulness, and a sense of agency is certainly consistent with the goals of the recovery movement (Jacobson & Greenley, 2001) in that recovery emphasizes client partnership in directing treatment and improvement in quality of life and not just symptoms. However, implementation of a money management program is not simple. A voluntary money management program requires staff training in counseling and in the management of an account with client funds (materials available for download at www.behavior change.yale.edu). Our data suggest that another barrier to the establishment of a voluntary money management program is the initial reluctance of clients to discuss finances with a therapist. With a focus on building trust and working collaboratively with the client, a money management program is more likely to be accepted. The relationship of a voluntary money management program to existing payee programs may complicate their adoption because of possible confusion between the voluntary and involuntary programs. It is important that agencies consider the duration of voluntary money management interventions, how the interventions are sequenced and fitted into the other services offered, and how money management programs are staffed.
Limitations Most ATM counseling was delivered by a single money manager, and study results were from only 15 participants. It is possible that different themes would have emerged if more client-money manager pairs had been studied. It is also possible that these participants, by virtue of being at the mental health center 1 year after the parent study and being willing to participate in the qualitative study, were more inclined to view money management favorably than those who did not participate. It is also possible that participants selectively remembered the aspects of the program they liked, as there is some benefit to remembering past efforts in a favorable light (e.g., Lyubomirsky & Tucker, 1998; Zhang & Howell,
Subjective Experience of Money Management 151 2011). Finally, it is unknown whether the experience of participants in this research study will be representative of experiences in future settings with other staff, clientele, and cultures.
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CONCLUSION This qualitative study suggests a number of benefits of voluntary money management, including client engagement in their own finances, client satisfaction with voluntary and therapeutic money management, and financial skills building for clients. These findings were accompanied with a reduction in cocaine use among those who participated in the ATM group, compared with the control group (Rosen et al., 2010). Future research should explore the benefits as well as difficulties associated with this form of financial assistance for persons with mental illnesses. It is also important to consider other stakeholders, such as family members, clinicians who work alongside money managers, and administrators who oversee the money management programs. Improved money management skills can translate into a marginal improvement in one’s economic standing and can assist those living with mental illness and their communities within the broader context of social and economic poverty. REFERENCES Angell, B., Martinez, N. I., Mahoney, C. A., & Corrigan, P. W. (2007). Payeeship, financial leverage, and client-provider relationship. Psychiatric Services, 58(3), 365–372. Bond, G. R., Drake, R. E., Becker, D. R., & Mueser, K. T. (1999). Effectiveness of psychiatric rehabilitation approaches for employment of people with severe mental illness. Journal of Disability Policy Studies, 10(1), 18–52. Brotman, A. W., & Muller, J. J. (1990). The therapist as representative payee. Hospital & Community Psychiatry, 41(2), 167–171. Conrad, K. J., Lutz, G., Matters, M. D., Donner, L., Clark, E., & Lynch, P. (2006). Randomized trial of psychiatric care with representative payeeship for persons with serious mental illness. Psychiatric Services, 57(2), 197–204. Dixon, L., Turner, J., Krauss, N., Scott, J., & McNary, S. (1999). Case managers’ and clients’ perspectives on a representative payee program. Psychiatric Services, 50(6), 781–786. Estroff, S. E., Patrick, D. L., Zimmer, C. R., & Lachicotte, W. S. (1997). Pathways to disability income among persons with severe persistent psychiatric disorders. Milbank Quarterly, 75(4), 495–532.
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